Prep U CH 39: Oxygenation and Perfusion
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is
"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment
5,850 mL (5,850 × 10^9/L)
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate
Check fit of oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen.
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action
Document this expected assessment finding.
Which skin disorder is associated with asthma
Eczema The client with asthma often recalls childhood allergies and eczema.
The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is
Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen
Instruct the client to inhale deeply and then cough.
During assessment of a 4-year-old client, the nurse notes a respiratory rate of 35 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next
Proceed with the assessment
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding
The adult chest contour is slightly convex, with no sternal depression.
What assessments would a nurse make when auscultating the lungs
cardiovascular function
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from
croup. Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.
Oxygen and carbon dioxide move between the alveoli and the blood by
diffusion.
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client
nasal cannula A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner
8 L/min oxygen via nasal cannula The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.
The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply
Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. MDIs deliver a controlled dose of medications with each compression of the canister. When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling.
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response
Maintain the client's oxygenation and alert the health care provider immediately.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client
Nasal cannula The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen.
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered
Nasal cannulaNasal cannula and tubing administers oxygen concentrations at 22% to 44%.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of
Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective
SpO2 92% An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action
Warm the client's hands and try again
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from
congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather
face tent
The nurse is planning a diet for a client with chronic obstructive pulmonary disease (COPD). Which recommended nutritional guidelines would the nurse discuss with the client? Select all that apply
The diet should contain 12% to 20% protein. The diet should consist of 40% to 55% carbohydrates. The diet should be rich in antioxidants and vitamins A, C, and B.
The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says
"Smoking only once in a while will not make a person addicted to smoking."
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines
Be sure to shake the canister before using it. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly.
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia
Confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level
Crackles
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat
Eat smaller meals that are high in protein. The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.
In which client should the nurse prioritize assessments for respiratory depression
A client taking opioids for cancer pain
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client
Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube.
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client
Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client
Flow meter The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations
Hypoxia Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen
It determines whether the client is getting enough oxygen.
A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant
Oxygen hood
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function
Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client
Pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom
Rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign
Respiratory rate and depth
When caring for a client with a tracheostomy, the nurse would perform which recommended action
Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds
They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client
Tracheostomy Collar
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding
True This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting
Vesicular
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing
a bronchospasm.
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's
hemoglobin level.
